Do You Believe Doctors Are Systems, My Friends?

In the current issue of The New Yorker, surgeon Atul Gawande provocatively suggests that medicine needs to become more like The Cheesecake Factory – more standardized, better quality control, with a touch of room for slight customization and innovation.

The core of the argument is this: the traditional idea that your doctor is an expert who knows what’s best for you is likely wrong, and is both dangerous and costly. Instead, for most conditions, there are a clear set of guidelines, perhaps even algorithms, that should guide care, and by not following these pathways, patients are subjected to what amounts to arbitrary, whimsical care that in many cases is unnecessary and sometimes even harmful – and often with the best of intentions.

According to this view, the goal of medicine should be to standardize where possible, to the point where something like 90% of all care can be managed by algorithms – ideally, according to many, not requiring a physician’s involvement at all (most care would be administered by lower-cost providers). A small number of physicians still would be required for the difficult cases – and to develop new algorithms.

A variant of this view, discussed by technologists such as Vinod Khosla, and commentators such as John Goodman, imagines that one day even the low-cost providers can be cut out of the loop, and patients (consumers) can do most of the work with their computer and perhaps a few gadgets.

Doctors, as you might expect, tend to reject this vision of standardization, as it ruthlessly undercuts the view that physicians are particularly wise, special, insightful – and worthy of autonomy – and instead seems to assert that medicine should be run like an assembly line, with limited opportunity for customization.

The patient perspective may be more complicated: on the one hand, it’s absolutely true that the current system generally fails even the most basic standards of customer service. There’s virtually nothing in the current system that appears to be designed around patients; Gawande shares an example about the care a patient received in the emergency room that could have been told, with few modifications, by virtually everyone I know, and holds true whether you’re talking about a small community hospital or one of the nation’s leading teaching centers.

In other words, learning a bit about customer service from The Cheesecake Factory – or a number of other industry-leaders – would do medicine a world of good.

On the other hand, I worry that a lot of medicine really isn’t quite as reducible, as standardizable, as many of the advocates and management gurus would like to believe, and by doing the classic economics trick of “assuming a can opener” – assuming medicine is standardizable because, gosh, wouldn’t it be nice if it were – these experts may not be helping as much as they’d like to imagine.

Patients deserve and increasingly demand far better “customer service” than they currently receive; at the same time, at least the patients who are fortunate enough to have physicians tend to give them surprisingly high marks. Critics contend this is how the system is harmful to patients – patients can be suckered by good bedside manner, and not realize how poor the care actually is.

Yet, I’d argue that given the incredibly limited amount of solid evidence for most things in medicine, the individual relationship between physician and patient can be of remarkable therapeutic value (although perhaps less so in surgery than in internal medicine).

Thus, while Gawande claims that “Patients just won’t look for the best specialist anymore, they’ll look for the best system,” I wonder whether this is generally true and realistic. While Romney was roundly criticized for suggesting that “corporations are people,” I wonder if Gawande is overreaching in making the reverse claim: essentially, that “doctors are systems,” and that patients should, and will, reach for the best system, not the best person.

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You make a legitimate point, David, in arguing the importance of the patient-doctor relationship. In fact, I believe that there are other relationships between care team members and patients that will be equally important if health care is to operate as a system. As autonomy versus standardization, I think they correlate roughly with the art and science of medicine. Autonomy is required in order to exercise clinical judgment regarding appropriate application of evidence-based practices to the individual case, given the patient’s presenting situation and circumstances. In this regard, variability is a good thing and expert judgment cannot be replaced by algorythm. However, there is also reason to demand that the best treatments be provided to patients, and that best should mean something more than subjective judgment.

Thank you for framing several key issues so clearly. I’ve discussed some of these challenges here ( http://thehealthcareblog.com/blog/2009/09/20/balancing-consistency-and-innovation-in-healthcare/ ) and here ( http://www.forbes.com/sites/davidshaywitz/2012/03/31/medicine-must-allow-for-customization-a-lesson-for-policy-makers-and-regulators/ ), and would also strongly recommend this WSJ commentary by Harzband and Groopman: http://online.wsj.com/article/SB10001424052702303404704577311641531125820.html?mod=WSJ_0_0_WP_2715_RIGHTTopCarousel_1 . I suspect many look at current system and dream of imposing a rigid, algorithm-based approach on nearly everyone, with view that this would ensure a minimum level of acceptable care and would provide a mechanism to iteratively improve care for all. Others regard that as a fairly dystopian vision and suspect there must be a less regimented, externally-imposed way to arrive at an improved level of care, which would celebrate rather than suppress the individuality that can be a strength of our current system. I suspect that unless doctors soon figure out for themselves how to do this, they are likely to be the unwilling recipients of change, rather than those who drive it — which would be a tremendous loss for all. By the way, strongly agree with value of all members of the care team; I focus on doctors because they are the ones who are typically viewed by critics as the main “problem.” Finally, I deeply resonate with your statement that the best treatment should be provided to patients, and I’ve frequently made this same point myself. I suspect the challenge is determining just what the best treatment for a patient really is — and the precision with which this can be prospectively determined.

Automation does have a place in care delivery as evidenced by protocols, guidelines and procedures. Practitioners currently employ autonomous modes of diagnosis management per credentials permitting legal degrees of latitude. Healthcare delivery methods need not be mutually exclusive. There is a merit for elements of Dr. Gawande’s argument. Healthcare costs reflect the 80/20 rule regarding the proportion of patient types and disease managment focus. While I agree that the doctor-patient relationship should ideally express “nuance and depth”, I’m unconvinced that this is the default. With physicians scheduling 15 min office visits, HMO’s and PPO’s dictating which physican is ‘in your network’ year to year- as a consumer, my expectation for healthcare delivery consists of a practitioner who is merely pleasant and accurate-but if I have to choose, I’ll take accuracy please.

Appreciate and generally agree with your thoughtful and articulate comments; it’s absolutely true that guidelines, checklists, etc can be useful, and I have highlighted this potential (and key proponents, including Pronovost and Gawande) with great admiration in a number of previous posts (e.g. http://www.forbes.com/sites/davidshaywitz/2011/10/23/improved-measurement-a-path-to-better-health-for-real-people/ ). My preference would be to see us develop greater facilitity for thoughtfully incorporating these genuinely useful elements, rather than out of pained desperation throwing away a system that while imperfect also has a number of exceptional attributes upon which we can build. I think it’s a false choice to say current system vs cheesecake factory, and I think we can (and must) evolve towards a better place.

Dr. Shaywitz: It’s between the waiter and patron at the restaurant table of medicine

Hospitals can be dangerous and inefficient; therefore it is easy to connect with Atul Gawande’s recent New Yorker essay “BigMed” suggesting that the streamlined, production processes found at the Cheesecake Factory can and likely will be applied to healthcare. Yet hospital care should not be confused with the full spectrum of healthcare. One must make the distinction between the cognitive process of medical diagnosis occurring in exam rooms, with the procedural basis of surgical care and hospital recovery. While Dr. Gawande has provided a wonderful revealing portrait of cost-effective, fast, food preparation and delivery at the CheeseCake Factory , he has focused on the process of creating the meal, not the process of deciding what meal to make. Successful surgery, for the wrong diagnosis, is a problem. If we are to solve some of healthcare’s largest failings we should focus on what happens as physicians try to address their patient’s problems, diagnose and make decisions, at the table of medicine called the exam room. Consider the continuum of the patient encounter, from first symptoms, through diagnosis and therapy at a restaurant called Med. At Med I spend all of my shifts with my patrons at my tables. This is an unusual restaurant since the patrons are never sure of what they want to eat and appear every 20 minutes with ever changing lists of unique groups of ingredients to share with me. There are varying ingredients and thousands of meals that can be created. The patrons know the ingredients, but not the meal that they would like to eat. From memory I respond to the customers list of ingredients and ask many questions, take the pulse and other vital signs of the customer, order blood samples, radiographic studies and then decide for the patron which meal their ingredients add up to. All from memory. At Med, restaurant patrons also ask for foods and “food tests” they have seen on television all purported to be risk free. Further complicating the process is my customer is not out for a fun and relaxing evening, they are in small booths in skimpy, open at the back gowns, often anxious and uncertain if they will be harmed or poisoned by my foods, or simply receive a meal they do not want. Some are in pain and some are depressed, while other customers are totally unrealistic about the meal that is to be delivered. You see at Restaurant Med, where patrons only can speak to their wait staff about ingredients, and demand the modern but unhelpful ovens they heard about from friends and the media, it is really difficult to create meals that patrons thoroughly enjoy. An appendectomy should be consistently performed and priced, but how do we consistently perform and price considering the ambiguity inherent in diagnosis itself? Unlike a restaurant, where customers choose a meal by ordering a meal, at restaurant Med some higher force gives an unfortunate person an undifferentiated and undiagnosed problem that needs and deserves an answer. As it turns out, none of the patrons really want to be eating at restaurant Med, as they always receive a meal they did not ask for. Patients do not choose their diagnoses from menus; doctors must discover and diagnose them. If your waiter tries to memorize all the orders at all the tables, you might get the wrong meal, and if your server is in a hurry, thai dipping sauce might be spilled on your new silk blouse. Likewise if physicians are in a rush, they might not take a thorough history, perform a complete physical exam, or have an accurate and thorough list of diagnostic possibilities, ultimately resulting in the wrong diagnosis. If your physician believes he or she can memorize all the questions, tied to all the possible diagnoses you also might receive the wrong diagnosis. With that wrong diagnosis you might end up in a hospital more efficient than the Cheesecake Factory with doctors efficiently ordering unnecessary tests, and performing wrong surgeries for the wrong diagnosis all with the ease and speed of the best assembly line on the planet. Diagnostic and patient management error caused by cognitive mistakes in the exam room are all too often overlooked and unmentioned in the discussion of repairing our broken healthcare system. There are over a billion outpatient visits in the US each year, and numerous studies have shown 15-20% of these visits have an inaccurate diagnosis. Autopsy data proves this, malpractice insurers know this, and policy makers avoid it. Add diagnostic error in the emergency room and walk-in clinics to error in the out-patient offices of medicine and you have more than 200 million errors. If we are to resolve some of healthcare’s deepest woes we need to address diagnostic errors and the decision-making occurring at the restaurant table of medicine, the exam room. A bright light needs to be shined on the simple fact that there is too much to know, to ask and to apply during a 15 minute encounter unless the patient has the simplest of medical questions or problems. Medical informaticists, researchers and innovative companies are focusing on this essential limitation of medical decision-making by designing information systems to be used by physicians at the point of care, during the patient encounter. Problem oriented systems can also be designed for use by patients in advance of the visit, and the future holds home-based information coordinated with professional clinical decision support. These new information tools are beginning to take the guessing out of which ingredients (symptoms) relate to the meals that the patient ultimately receives (diagnosis and treatment). If medical care is truly to be driven back to primary care we need to arm the waiters of medicine with purposefully designed tools and training to resolve ambiguity, aid diagnosis and inform therapy in the exam room.

Art Papier MD Art Papier MD is CEO of Logical Images the developer of www.visualdx.com a clinical decision support system, Associate Professor of Dermatology and Medical Informatics at the University of Rochester College of Medicine, and a Director of the Society To Improve Diagnosis In Medicine (SIDM) http://www.improvediagnosis.org/

Dr. Gawande is correct, “Patients just won’t look for the best specialist anymore, they’ll look for the best system.” And they’ll end up getting both because the best doctors will look for the best system as well.